Expert Guidelines: How long to hold ELIQUIS before hip fracture surgery?

October 14, 2025 •

3 min read

Hip fracture surgery is often an emergency procedure, yet over 50% of patients on Direct Oral Anticoagulants (DOACs) like ELIQUIS experience surgical delays of more than 24 hours. Balancing the risk of excessive bleeding with the dangers of surgical delay is a critical consideration for managing how long to hold ELIQUIS before hip fracture surgery.

Quick Summary

The decision to temporarily hold ELIQUIS for hip fracture surgery depends on renal function and procedural bleeding risk. Standard guidance recommends a 48-hour hold for high-risk procedures, but urgency and renal impairment may alter this timeline. Careful assessment by a multidisciplinary team is essential to balance bleeding risks and surgical delays.

Key Points

Standard Hold Time: For a high-bleeding-risk procedure like hip fracture surgery, the standard recommendation is to hold ELIQUIS for at least 48 hours.
Renal Function Matters: Impaired kidney function can prolong the clearance of ELIQUIS, requiring a longer hold time (e.g., 72 hours or more) before surgery.
Emergency vs. Elective: Hip fracture surgery is often urgent, and delaying surgery beyond 24-48 hours is associated with worse patient outcomes, creating a critical timing dilemma.
No Bridging Therapy: Unlike warfarin, ELIQUIS has a rapid onset and offset, so bridging anticoagulation with heparin is generally not required during the perioperative period.
Reversal Agents: For life-threatening bleeding in emergency cases, a reversal agent like andexanet alfa may be used to counteract apixaban's effects.
Multidisciplinary Approach: A safe perioperative plan for hip fracture patients on ELIQUIS requires close coordination between surgeons, anesthesiologists, and hematologists.
Postoperative Resumption: ELIQUIS is typically restarted 12 to 72 hours after surgery once adequate hemostasis is confirmed, based on bleeding risk and hospital protocol.

Understanding the Need to Stop Anticoagulants Before Surgery

ELIQUIS (apixaban) is a direct oral anticoagulant (DOAC) that inhibits factor Xa to prevent blood clots. Stopping this medication before surgery is essential to prevent excessive bleeding. Hip fracture surgery is often urgent, and while guidelines exist for holding anticoagulants, delaying surgery can lead to complications. The approach involves balancing the risks of bleeding and surgical delay.

Factors Influencing the ELIQUIS Hold Period

Several factors determine how long ELIQUIS should be held:

Bleeding Risk: Hip fracture surgery is a high-bleeding-risk procedure. The standard recommendation is to hold ELIQUIS for at least 48 hours.
Renal Function: Impaired kidney function affects how quickly ELIQUIS is cleared from the body, requiring longer hold times. For moderate impairment, 72 hours or more may be needed, while severe impairment could require 96 hours or longer.
Reason for Anticoagulation: The patient's underlying condition for taking ELIQUIS influences the risk of blood clots if the medication is stopped.

The Urgent Nature of Hip Fracture Surgery

Delaying hip fracture surgery is associated with increased risks of complications and mortality. While standard hold times are recommended, some studies suggest that earlier surgery might be safe under specific protocols. A multidisciplinary team approach is vital for making decisions in urgent cases, especially when considering renal function and delaying surgery.

Comparing Hold Times Based on Clinical Factors


Clinical Factor	Recommended ELIQUIS Hold Time	Rationale
Standard (Normal Renal Function)	At least 48 hours before a high-bleeding-risk procedure like hip fracture surgery.	This period allows for sufficient clearance of apixaban from the blood in most patients with healthy kidneys.
Moderate Renal Impairment (CrCl 30–50 mL/min)	72 hours or longer, depending on specific hospital protocol.	Reduced kidney function prolongs the drug's half-life, meaning more time is needed for the anticoagulant effect to diminish.
Severe Renal Impairment (CrCl <30 mL/min)	Up to 96 hours or more; a hematology consultation is typically required.	The risk of drug accumulation and bleeding is much higher, requiring a more cautious approach and expert consultation.
Neuraxial Anesthesia (Epidural/Spinal)	72 hours before the block.	This is a specific safety guideline from the American Society of Regional Anesthesia and Pain Medicine (ASRA) due to the risk of spinal hematoma.

Managing Anticoagulation in an Emergency

In emergency situations where standard hold times are not feasible, a multidisciplinary team will assess the risks. For life-threatening bleeding, a reversal agent for apixaban, such as andexanet alfa, may be used. The decision to proceed with surgery earlier than the standard hold time is made based on balancing bleeding risks and the risks of delaying surgery.

Resuming ELIQUIS After Surgery

Resuming ELIQUIS safely after surgery is as important as stopping it. It is typically restarted 12 to 72 hours post-surgery once bleeding is controlled. The timing depends on the risk of bleeding after the procedure and the individual's risk of blood clots. Protocols may vary, and resumption should be guided by the medical team. Information on resuming ELIQUIS and perioperative management can be found from sources like the American College of Cardiology.

Conclusion

Determining how long to hold ELIQUIS before hip fracture surgery requires careful consideration of bleeding risks, renal function, and the urgency of the procedure. While a 48-hour hold is standard for high-risk procedures with normal renal function, individual patient factors and the need to avoid surgical delays in hip fracture cases necessitate a tailored approach. Multidisciplinary consultation is key to optimizing patient safety. Always follow your healthcare provider's specific instructions for managing your medication around the time of surgery.

Frequently Asked Questions

For a standard 48-hour hold before major surgery, a patient typically skips four doses of ELIQUIS, assuming a twice-daily regimen. However, this can be longer if you have impaired kidney function.

The medical team needs to know immediately. In an emergency setting, doctors may need to use a reversal agent or adjust surgical timing based on the last dose taken. Your doctor will make a risk-benefit assessment.

For neuraxial anesthesia, such as an epidural or spinal block, the American Society of Regional Anesthesia and Pain Medicine recommends holding ELIQUIS for at least 72 hours to prevent the risk of spinal hematoma.

Delaying hip fracture surgery beyond 24-48 hours has been associated with an increased risk of complications, including higher mortality rates, especially in elderly patients.

Kidney function is a key factor, as it affects how quickly your body clears apixaban. A patient with normal function may need a 48-hour hold, while someone with moderate renal impairment might require 72 hours or longer.

Restarting is determined by your surgeon and anesthesiologist. It is typically resumed 12-72 hours after surgery, once there is no significant bleeding risk. The exact timing and dosage will be tailored to your case.

No, bridging therapy with heparin is generally not required when interrupting ELIQUIS for surgery. Unlike warfarin, DOACs have a rapid onset and offset, making a short interruption sufficient for most patients.